The Washington Post
Washington — Senate Republican leaders are aiming to bring a major revision to the nation’s health-care laws to the Senate floor by the end of June even as lingering disagreements, particularly over Medicaid, threaten to derail their efforts, several Republicans familiar with the effort said on Thursday.
President Donald Trump and Senate Majority Leader Mitch McConnell, R-Ky., are both pressing for an ambitious timeline to complete the bill, although it is being drafted in the Senate with little assistance from the White House.
The push has been laden with secrecy — and rank-and-file Republican senators are increasingly frustrated that McConnell and a small group of GOP aides are crafting a bill behind closed doors.
“My primary concern is writing a bill and not having enough time to analyze it,” said Sen. Ron Johnson, R-Wis., in an interview this week. “I don’t want to get jammed.” Asked to describe his concerns with the process, Johnson quipped, “How much time do you have?”
Impassioned policy disputes have flared among some GOP senators in large group meetings at which McConnell has floated ideas from the drafting process. But those disputes have not deterred him from the goal of a floor vote before the July 4 recess, said the Republicans familiar with the process, who spoke on the condition of anonymity.
In public this week, McConnell and other Republican leaders have hedged their aggressive timeline. But, as McConnell’s team sees it, the options have all been vetted. Now, the difficult decisions about what to put in and leave out of the final bill are all that remain.
“We’ve been dealing with this issue for seven years,” McConnell said this week. “We’re now working on coming up with a solution.”
Another X Factor is Trump’s shifting position on the legislation. Just this week, he called the House version “mean” — causing concern about how forcefully he will support the Senate bill in the coming weeks.
By all accounts, the Senate bill will be dramatically different from the measure that emerged from the House in May, and it is entirely unknown how and whether the two chambers can reconcile their differences and actually enact legislation revising the Affordable Care Act, known commonly as Obamacare.
Equally unclear is how McConnell can get to 50 votes in his chamber, with Vice President Mike Pence at the ready to cast a tiebreaking vote. The difficulties underscore the tension between Republicans’ longstanding goal of repealing and replacing Obamacare and their growing sense that enacting legislation that knocks millions of Americans off of the insurance rolls is politically treacherous. Because of that tension, the Senate bill is far more likely to revise the Affordable Care Act than to replace it.
The largest, most enduring clash within the Senate is over the future of Medicaid. Republican senators are at odds over how much and how quickly to pare back federal spending on the program, which expanded under Obamacare and added millions of Americans to the rolls of the federally insured.
Other questions to be resolved include how many and which of the ACA taxes to keep and which regulations to eliminate. McConnell has proposed preserving protections for people with preexisting medical conditions in the current law, which the House bill does not do.
The Medicaid fight has flared frequently in recent weeks as two Rust Belt senators with starkly different views of the program have become leaders of competing factions in the closed-door meetings: Rob Portman of Ohio and Patrick Toomey of Pennsylvania. Portman and others from states that expanded Medicaid under the ACA want more time to unwind the program while Toomey and his conservative allies want to slow the growth of the program’s cost.
The two have clashed several times in closed-door gatherings, according to several Republican senators and aides familiar with the meetings. Portman is fighting a proposal from Toomey and conservative Sen. Mike Lee, R-Utah, to cut Medicaid spending by capping federal payments at a rate slower than Medicaid costs are currently expected to rise. Toomey and his supporters believe their plan would help curb the long-term costs of Medicaid.
Portman and several other moderate senators believe the proposed cuts would give states no choice but to cut services, benefits or provider payments and could leave people with insufficient care.
“We need to come together around a more workable system that not only lowers costs, but also protects the most vulnerable in our society,” Portman said in a statement.
The intense disagreement has also included Sen. Tom Cotton, R-Ark., who is allied with Toomey, and who recently engaged Portman in a frank and lengthy exchange.
Portman is also working with Sen. Shelley Moore Capito, R-W.Va., to push for $45 billion over 10 years to address opioid addiction. Capito told reporters Tuesday that opioid money is among her top priorities.
“It’s absolutely critical to my state, and we’ve got huge problems,” Capito said.
Sen. Roy Blunt, R-Mo., a top McConnell deputy, said confrontations such as those between Toomey and Portman are the result of senators spending the past several years learning the minute details of the health care policies that work best in their states. “These debates have a higher quality of intensity on detail than they would have in the past,” Blunt said.
Republican leaders have no plans to hold committee hearings on their bill. They feel like they have spent plenty of time presenting GOP senators with different options. No Democrats are expected to support it. But some Republican senators say they have been left in the dark about what’s in the emerging bill or are concerned about moving ahead too quickly.
“You really would need to ask Sen. McConnell or his staff that,” said Sen. Susan Collins, R-Maine, a swing vote, when asked about how much of the bill has been written. “I’m not part of his working group.”
Leaders have also been in frequent contact with the nonpartisan scorekeepers at the Congressional Budget Office. The constant dialogue is expected to make it easier for the CBO to determine the cost of the final bill and further speed up the timeline before a final vote.
Some have also complained about overly general material in PowerPoint presentations delivered quickly during policy lunches.
McConnell, top aides from the offices of Republican Whip John Cornyn, R-Texas, and staffers from three key committee have maintained tight control of the process, going to great lengths not to put anything on paper to avoid leaks. At least one senator complained that the digital slides are flashed across the screens so quickly that they can hardly be committed to memory.
Trump met with senators this week at the White House to talk about health care, and he supports a quick timeline, according to one senior administration official.
But compared to earlier this year, when the House bill was under debate, he has taken a more hands-off approach, leaving much of the work to the senators.
Trump called the bill “mean” during a lunch with GOP senators on Tuesday — despite having championed the legislation and celebrating its passage in a Rose Garden ceremony. He also said that the Senate bill needed to be more generous.
That language led to worries in both chambers that Trump might not support members who take tough votes on health care, even if it isn’t as popular as he had hoped, according to one Republican policy expert who is close to both the White House and congressional process.
“The president’s off-handed comment to a group of senators was actually a huge shock to the system,” that person said. “That confirmed a worry that a lot of people have had on the Hill about Trump and what he would do if the bill they’re working on turned out to be less popular than they expected.”
Senate leaders argued that they are keeping a tight grip on emerging bill language a secret because they are writing several different policy options for each section of the bill. They worry that sharing any one piece out of context could give a distorted impression of what the final bill will include.
“There’s going to be trade-offs,” Cornyn said. “We’re trying to do this in a careful, thoughtful sort of way.”